With an expectant smile and raised eyebrows, my patient watched me enter the exam room. Dressed in slacks with a straight crease and neat shirt, he was looking for an answer.
Almost 24 weeks ago to the day he had begun treatment for his hepatitis C, a virus that had been in his liver and blood stream for decades. He diligently took the once-a-day pill for 12 weeks and together we waited another 12 to see if he would be cured.
My first encounter with this virus was during my internship in 1979. One of my patients had jaundice, his skin a deep yellow, and the whites of his eyes transformed into an alien-looking yellow green. His liver was failing, unable to do the normal work of filtering the blood.
At the start of the year, I wasn’t particularly adept at starting intravenous lines or drawing blood. This patient had encephalopathy, a clouding of his consciousness due to liver failure, making my usual warnings about the impending needle stick, superfluous, or so I thought.
Holding his forearm down on the bed with my left hand, I carefully aimed the needle for a particularly large vein and plunged in. Startled the patient yelped, jerked his arm and I stabbed myself.
Blood from my finger oozed out underneath my yellow glove in an alarming fashion.
By the time I was an intern, both hepatitis A (transmitted in food) and hepatitis B (transmitted in blood and sex) had been identified. But there was a third kind, called “non-A, non-B” at the time, that was also transmitted in blood, and scientists had not yet discovered its cause. With no vaccines available at that time, thousands of health care workers were infected each year with hepatitis B or non-A/non-B hepatitis, and several hundred died annually from acute infection or longer-term complications. It was just the risk of doing business.
Knowing that risk, I notified employee health. Within minutes of my injury, my pants were around my ankles as I lay bent over the exam table, medical paraphernalia spilling out of my pockets. The nurse eyed my pale buttocks with a professional eye, and plunged a large syringe filled with amber-colored liquid, plasma obtained from donors hopefully containing antibodies to protect me from acquiring hepatitis.
It was a painful remainder to be more careful with semi-conscious patients. Without a blood test to diagnose this unknown virus, I had to wait weeks to see if I would become sick.
In 1981, a vaccine against hepatitis B became available, health care workers routinely get it, and infection rates are way down. But non-A/non-B was still a mystery. It wasn’t until 1989 that scientists at Chiron Corporation discovered that non-A/non-B was actually caused by hepatitis C. In 1990 a diagnostic blood test was approved, and blood transfusions, already screened to weed out any positive for hepatitis B, started being screened for hepatitis C as well.
We now know that Hepatitis C can cause both acute and chronic hepatitis. Chronic infection is often progressive and can ultimately lead to liver failure and liver cancer. Approximately 3.5 million Americans are infected with hepatitis C, and only half know it. Thousands die each year from the virus or its complications.
Fortunately, there is now effective and curative drug treatment, but getting it to all who need it is challenging. In early 2016, we started screening everyone for hepatitis C in the Open Door Clinic at Urban Ministries of Wake County. Staffed by volunteers, the clinic is open to people who don’t have insurance and don’t qualify for insurance. To our surprise 3 percent were infected, almost all without any symptoms and unaware that they were infected.
Having consulted on hepatitis C treatment projects in Ukraine and Burma, where the epidemic is even larger and the resources less, I modified the usual treatment protocol for our clinic to decrease the number of blood tests and clinic visits to only three over 6 months. This made it less costly and easier on the patients, allowing me to treat many more despite volunteering at the clinic only twice weekly.
With the ability to now cure people infected with hepatitis C, if we treat enough patients we have the possibility of blocking the spread and eradicating the virus from entire communities. By testing more people at risk of infection, making treatment locations easily accessible to the people who need it, and simplifying the treatment protocols, this public health challenge can be overcome.
My patient, like many of the people I have treated for hepatitis C, faced many challenges. One of the great joys in volunteering at Open Door is the time I get to spend with the patients, listening to and learning from them. Each is a portrait of strength despite enormous hurdles. Not only do they lack health insurance, they juggle multiple medical conditions and medications, try to keep clinic appointments despite demanding minimum wage work, lack of transportation and inadequate public transit.
A quarter of a century after my painful butt shot, it is perpetually wondrous to celebrate with my patients as we check at least one problem off their list. With unrestrained joy, I gave my patient a high five and said, “Congratulations, you did it!”
Charles van der Horst, M.D., is an emeritus professor of medicine at UNC and a global health consultant. Follow him on Twitter @chasvanderhorst. Learn more about Open Door clinic at https://www.urbanmin.org/open-door-clinic/